The association between flavor capsule cigarette use and sociodemographic variables: Evidence from Chile

Use of flavor capsule cigarettes and their preliminary impact on smoking cessation in Mexico: an exploratory study

BACKGROUND

No study has assessed the impact of flavor capsule cigarettes (FCCs) on smoking cessation. Thus, the purpose of this exploratory study was to assess (1) the sociodemographic and smoking-related characteristics associated with using FCCs, and (2) the preliminary impact of FCCs on smoking cessation.

METHODS

This study is a secondary data analysis of a single-arm study with 100 individuals living in Mexico who smoked and received a smoking cessation mHealth intervention and pharmacotherapy support. The primary outcomes were self-reported and biochemically verified 7-day smoking abstinence at Month 3.

RESULTS

Just over one-third of participants (36%) used FCCs, with a preference for one capsule and menthol/mint flavor. Compared to participants who smoked non-FCCs, participants who smoked FCCs were (1) younger, (2) more likely to be women, and (3) more likely to smoke less than 10 cigarettes per day (CPD; all p's < 0.05). After controlling for all significant associations, age younger than 50 years old (AOR = 3.26, 95% CI 1.25-8.51) and being a woman (AOR = 3.62, 95% CI 1.41-9.35) were positively and independently associated with smoking FCCs. Treating those lost to follow-up as participants who continued smoking, 41.7% (15/36) of participants who smoked FCCs self-reported smoking abstinence at month 3 compared to 42.2% (27/64) of participants who smoked non-FCCs (p = 0.96). Furthermore, 33.3% (12/36) of participants who smoked FCCs were biochemically verified abstinent at Month 3 compared to 18.8% (12/64) of participants who smoked non-FCCs (p = 0.10).

CONCLUSIONS

Younger age and being a woman were associated with using FCCs. Self-reported smoking abstinence at Month 3 was comparable between participants who smoke FCCs and non-FCCs. However, biochemically verified abstinent at Month 3 was higher among participants who smoke FCCs compared to participants who smoke non-FCCs, although the difference was not statistically significant. Prospective and adequately powered comparisons must be made between individuals who smoke FCCs and non-FCCs to effectively assess differences in smoking abstinence, and the reasons for these differences.

The Use of Packaging Descriptors in a Rapidly Growing Market for Capsule Cigarettes: Evidence From Mexico

INTRODUCTION

The global market for capsule cigarettes has grown rapidly, especially in Latin America. This research examined the sales trends and patterns as well as packaging characteristics of capsule cigarette in Mexico in recent years.

METHODS

National data on cigarette sales in Mexico between October 2018 and September 2021 licensed from NielsenIQ were supplemented with cigarette pack pictures and Internet searches to determine whether characterizing flavor, concept flavor, and action descriptors were used. Market share in sales value and volume was calculated by capsule and flavor status, descriptors, price tier, manufacturer, pack size, and cigarette length for the whole time period and for each month. Number of unique brand variants was also examined.

RESULTS

Capsule cigarette sales totaled US$4.29 billion or 30.99 billion sticks during the assessed period, comprising 37.7% of the cigarette market share in sales value or 35.5% in sales volume. Over half of capsule cigarettes sold during this time period had concept flavor descriptors, 17.8% contained characterizing flavor descriptors, and 15.1% contained action descriptors that were suggestive of the interactive aspects of capsules. The monthly market share of capsule cigarette sales volume among all cigarette sales in Mexico increased steadily from 33.3% in October 2018 to 37.3% in September 2021.

CONCLUSIONS

The expanding capsule cigarette market in Mexico is concerning, given the product's associated misconceptions of reduced harm and greater appeal among youth. Findings underline the need for enhanced regulations to address the public health threat posed by capsule cigarettes.

IMPLICATIONS

Capsule cigarettes have a substantial market share in Mexico, with increasing popularity. Descriptors and other product characteristics such as cigarette length might be used to increase the appeal and target particular populations. Policy makers should consider banning capsules and flavors in cigarettes including descriptors or other indication in product presentation that could be perceived as denoting a taste, aroma, or sensation, and making the appearance and design of tobacco products more commensurate with the harm they cause by adopting plain and standardized packaging.

Chemicals in Cigarette Flavor Capsules From Guatemala and Mexico

BACKGROUND

The global market share for cigarettes with flavor capsules has grown exponentially over the last decade, particularly in Latin America. When smoking, consumers crush a liquid capsule in the filter that flavors the smoke. Little is known about the chemical constituents of the liquids in capsules or their potential health risks.

METHODS

Based on consumer data and availability in Mexico and Guatemala, 31 flavor capsule brands were purchased (19 and 12, respectively) in 2020. Since some cigarettes included multiple capsules in a stick (up to 2) or pack (up to 4), the final analytic sample included 50 capsules. We conducted qualitative and quantitative analyses using gas chromatography with mass spectrometry (GC-MS, Agilent Technologies, Inc).

RESULTS

The qualitative analysis detected 296 compounds (range = 9-67 per capsule), and all capsules contained menthol. Among the compounds detected in more than half the sample were limonene, menthone, benzaldehyde, eucalyptol, and triacetin. Traces of nicotine were found in 22% of the capsules. In the quantitative analysis, menthol concentrations were 33 times greater than the next most common compound (limonene). Benzyl alcohol and vanillin were also found in high concentrations. Comparing same-brand varieties across countries showed substantial variability in the concentration of menthol and other compounds.

CONCLUSIONS

Menthol is an omnipresent constituent in capsule cigarettes, perhaps because of its anesthetizing and reinforcing addictive properties. Other compounds found are toxic, potentially carcinogenic, and may enhance addictiveness. Variance in the presence and concentrations of such compounds highlights the importance of product standards to regulate capsule content.

IMPLICATIONS

This study evaluated the chemical content of capsule cigarettes from two Latin American countries that have two of the highest market shares for capsule cigarettes worldwide. Compared to other studies, our assessment included brand varieties from two countries to compare the differences in chemical content by country. Our results yield that menthol is found in all capsules, and that other chemicals found may prolong nicotine exposure and therefore reinforce the addictive properties of cigarettes.

Prevalence and perceptions of flavour capsule cigarettes among adults who smoke in Brazil, Japan, Republic of Korea, Malaysia and Mexico: findings from the ITC surveys

INTRODUCTION

The global market of flavour capsule cigarettes (FCCs) has grown significantly over the past decade; however, prevalence data exist for only a few countries. This study examined prevalence and perceptions of FCCs among adults who smoke across five countries.

METHODS

Cross-sectional data among adults who smoked cigarettes came from the International Tobacco Control Policy Evaluation Project Surveys-Brazil (2016/2017), Japan (2021), Republic of Korea (2021), Malaysia (2020) and Mexico (2021). FCCs use was measured based on reporting one's usual/current brand or favourite variety has flavour capsule(s). Perceptions of the harmfulness of one's usual brand versus other brands were compared between those who used capsules versus no capsules. Adjusted logistic regression models examined correlates of FCC use.

RESULTS

There were substantial differences in the prevalence of FCC use among adults who smoke across the five countries: Mexico (50.3% in 2021), Republic of Korea (31.8% in 2021), Malaysia (26.5% in 2020), Japan (21.6% in 2021) and Brazil (6.7% in 2016/2017). Correlates of FCC use varied across countries. Capsule use was positively associated with being female in Japan and Mexico, younger age in Japan, Republic of Korea and Malaysia, high education in Brazil, Japan and Mexico, non-daily smoking in Republic of Korea, and having plans to quit in Japan and Republic of Korea. There was no consistent pattern of consumer perceptions of brand harmfulness.

CONCLUSION

Our study documented the high prevalence of FCCs in some countries, pointing to the need to develop and implement regulatory strategies to control these attractive products.

Determinants of Hardcore Smoking in a MULTI-ETHNIC Study of Cigarette Smokers in Singapore

Smokers who are resistant to quitting are not well studied in Asia, particularly in multi-ethnic populations. We compared the characteristics of hardcore smokers in Singapore, a multi-ethnic Asian population, with other daily smokers, and investigated the role of ethnicity as an effect modifier on identified determinants, including cigarette flavor preferences, using cross-sectional data from Singapore Smokers' Survey (n = 1,501). Multivariable logistic regression was used to assess the association. 22.8% of adult daily smokers were hardcore smokers. Novel findings on hardcore smokers' preference for regular flavored cigarettes (AOR = 1.54; 95%CI: 1.14, 2.07) suggest there is room for interventions among hardcore smokers through regulation of cigarette flavors and nicotine content. Although ethnicity was not a significant factor, it was an effect modifier with peers' disapproval of smoking (p-value for interaction = 0.024), significantly lowering odds of Malays being hardcore smokers (stratified odds ratio, AOR stratified, Malay = 0.35; CI: 0.17, 0.71), but not Chinese (AOR stratified, Chinese = 1.27; CI: 0.70, 2.42) and Indian smokers (AOR stratified, Indian = 0.62; CI: 0.18, 2.28), suggesting that smoking cessation policies utilizing social norm change strategies may be more effective when tailored to the differing roles of peer norms among different ethnic groups, in Singapore and other multi-ethnic Asian populations.

Tobacco industry pricing strategies for single cigarettes and multistick packs after excise tax increases in Colombia

INTRODUCTION

Taxes on tobacco products are an efficient way of reducing consumption. However, they are only effective if passed on to consumers with higher prices. This study aims to examine tobacco industry (TI) pricing strategies in response to tax increases, and whether they differ by price segments or presentation (packs or individual sticks) in Colombia. This is the first such academic study in Latin America and the first anywhere to include the market for single sticks.

METHODS

Using data on cigarette pricing/taxation from a survey of smokers (2016-2017) and official government data on pricing (2007-2019), the TI's pricing strategies were examined, split by brand, price segments, different sized packs and single cigarettes.

RESULTS

The TI employed targeted pricing strategies in Colombia: differentially shifting taxes; and launching new brands/brand variants. The industry overshifted taxes when increases were smaller and predictable, but used undershifting more when there was a larger increase in 2017, after which it mostly overshifted on budget and premium (but undershifted mid-priced) brands. The prices for single sticks increased more than the tax increase in 2017 when their consumption also increased.

CONCLUSION

The pricing strategies identified suggest excise taxes can be increased further, particularly the specific component, to reduce the price gap between brand segments. Brands should be restricted to a single variant along with prohibitions on launching new brands/brand variants. Lastly, since the pricing of single sticks does not match the pattern of packs, more monitoring of their sales and distribution is required, especially since they promote consumption and hinder effective implementation of tobacco tax policies.

Price differences between capsule, menthol non-capsule and unflavoured cigarettes in 65 countries in 2018

The global consumption of flavoured cigarettes, particularly capsule and menthol non-capsule cigarettes, has been rising rapidly. Their attractiveness has been fuelled by perceptions of improved palatability, along with industry marketing tactics such as lower price points in some regions. This study aimed to compare prices of unflavoured, capsule, and menthol non-capsule cigarettes across 65 countries by analysing 2018 cigarette price data from Euromonitor Passport. Median prices of capsule and menthol non-capsule cigarettes were each compared to unflavoured cigarettes at the country-level. Countries were included in the analysis if they contained price data for capsule or menthol non-capsule and unflavoured cigarettes (n = 65). The median price of capsule cigarettes was the same as unflavoured cigarettes in 12 out of 50 countries and not statistically different in another 31 countries (p > 0.05). Capsule cigarettes were more expensive than unflavoured cigarettes in five countries and cheaper in two (p < 0.05). The median price of menthol non-capsule cigarettes was the same as unflavoured cigarettes in 6 out of 51 countries and not statistically different in another 39 countries (p > 0.05). Menthol non-capsule cigarettes were more expensive than unflavoured cigarettes in five countries and cheaper in one country (p < 0.05). There was no pattern found in the pricing of capsule or menthol non-capsule cigarettes, suggesting variability in the tobacco industry's pricing strategies across countries. Tailoring tobacco control policies to match national market conditions, particularly in countries with significant market shares of capsule and menthol non-capsule cigarettes could help address the public health threat posed by the tobacco epidemic.

Flavour capsule cigarette use and perceptions: a systematic review

OBJECTIVE

This systematic review on flavour capsule cigarettes aims to examine prevalence, correlates of use, behaviours and perceptions of these products globally.

DATA SOURCES

A search of original, peer-reviewed research without restrictions in publication year, population, study design or language, using a combination of cigarette and capsule terms was conducted across four databases (Medline, Embase, Web of Science and Scopus), indexed until 30 April 2021.

STUDY SELECTION

Studies were included if they presented original, human subjects research on flavour capsule cigarettes.

DATA EXTRACTION

Two authors independently extracted data on main outcome results and assessed risk of bias using a validated quality assessment tool (QATSDD).

DATA SYNTHESIS

Of 842 unduplicated database records and four studies from citation searching screened, 20 studies were included in the review. Studies reported data from 2009 to 2019 across eight countries, the majority of which used cross-sectional or focus group study designs. Current capsule use among smokers was highest in Chile and Mexico (40%) and was associated with younger age, and in some countries, with being female. Capsule cigarettes are perceived as tasting better, being smoother on the throat, more fun to smoke, and more attractive compared with non-capsule cigarettes, particularly among susceptible non-smokers and non-daily smokers.

CONCLUSION

Findings call for the adoption of comprehensive tobacco control policies that account for flavour capsules and similar iterations, which can increase appeal through flavours and innovative features. Continued monitoring and research of these products is critical, with particular attention to low-income and middle-income countries, which make up a disproportionately larger share of the capsule market.

Sensory methods to evaluate perception of flavours in tobacco and other nicotine-containing products: a review

OBJECTIVES

Sensory methods use human senses to evaluate product attributes. This review provides an overview of the types of sensory methods used to evaluate the perception of flavour in tobacco and other nicotine-containing (ToNic) products and to discuss how sensory data could inform flavoured ToNic product policy.

DATA SOURCES

PubMed, Embase and Web of Science.

STUDY SELECTION

All peer-reviewed studies evaluating ToNic products using a sensory method published before 23 May 2020.

DATA EXTRACTION

Two independent coders completed title/abstract and full-text screening to choose articles for inclusion (Cohen's kappa=0.85, strong agreement). Each coder completed data extraction on half the articles, recording relevant information (eg, sensory methods used, results). The coders categorised sensory methods and generated overarching themes.

DATA SYNTHESIS

Of 110 articles identified, we included 29 articles containing 35 studies that used sensory methods to investigate ToNic products. The sensory methods included analytic methods such as discrimination and descriptive tests and hedonic methods such as liking tests. Six themes emerged regarding how sensory methods can be used to understand consumer perception and liking of ToNic products and to inform ToNic product policy.

CONCLUSIONS

The identified studies highlight that sensory data can inform ToNic product policy. Analytic and sensory hedonic ratings can be used to assess a ToNic product's ability to promote addiction in the user (ie, abuse liability). Lastly, hedonic ratings can provide information to assess potential use behaviours.

Marketing of flavour capsule cigarettes: a systematic review

OBJECTIVE

This systematic review aims to identify marketing elements of flavour capsule variants (FCVs), cigarettes that release flavour when a capsule(s) embedded in the filter is crushed.

DATA SOURCES

A search of original research without restrictions in publication year, population, study design or language using a combination of cigarette and capsule terms was conducted across four databases (Medline, Embase, Web of Science and Scopus), indexed until 13 December 2021, along with a citation search.

STUDY SELECTION

Studies were included if they presented original research relevant to marketing features of FCVs.

DATA EXTRACTION

One author performed data extraction and coded outcomes based on '4Ps' of marketing mix theory: product, place, price and promotion. The second author conducted a cross-check.

DATA SYNTHESIS

Of 2436 unduplicated database records and 30 records from other sources, 40 studies were included in the review. Studies were published between 2009 and 2021. Study methodologies primarily included content analysis of cigarette packs/sticks, review of tobacco industry documents and content analysis of advertising information. Findings suggest FCVs are marketed using a mix of strategies, particularly characterised by product innovation, timing market launches around tobacco policies, point-of-sale advertising and packaging to communicate a high-tech, customisable and flavourful product.

CONCLUSION

Findings illuminate the marketing strategies of FCVs that are likely driving their global growth, particularly among young people and in low and middle-income countries. Comprehensive tobacco control regulations are needed to close loopholes and curb industry efforts to circumvent existing policies in order to mitigate uptake of FCVs and other product innovations.

First tobacco product tried and current use of cigarettes and electronic cigarettes among adolescents from Guatemala City

OBJECTIVE

To assess how first experimenting with ciga-rettes or e-cigarettes is associated with current use in Gua-temala, a middle-income country with weak tobacco control and no e-cigarette regulations.

MATERIALS AND METHODS

We surveyed students from private schools in Guatemala City, limiting analyses to ever users (n=1 026). Multinomial logistic models regressed current product use on first product used, adjusting for sociodemographics and friends and family use.

RESULTS

The most common first product used was e-cigarettes (56%), followed by flavored cigarettes (24%) and regular cigarettes (20%). At the time of the survey, 4% were exclusive smokers, 37% were exclusive e-cigarette users, 18% dual users, and 40% had ever tried either but were not current users. Compared to those who first tried cigarettes, students who first tried e-cigarettes were less likely to be current smokers (RR=0.19 [CI: 0.11,0.31]) or dual users (RR=0.26 [CI: 0.14,0.49]) and students who first tried flavored cigarettes were more likely to be current smokers (RR=1.66 [CI=1.13,2.42]).

CONCLUSIONS

In our sample, Guatemalan adolescents from private schools more frequently experiment and continue to use e-cigarettes than cigarettes. There is urgent need to implement e-cigarette restrictions in addition to tobacco control policy implementation.

Why Smoke Flavor Capsule Cigarettes? Preferences and Perceptions Among Adult Smokers in Mexico

INTRODUCTION

Flavor capsule cigarettes are rapidly gaining global market share, particularly in Latin America; however, little is known about consumer profiles and perceptions since the diffusion of this product innovation has become more widespread.

AIMS AND METHODS

This paper compares profiles and perceptions of smokers who prefer flavor capsule cigarettes and those who do not in Mexico. We analyzed data from six online surveys of adult Mexican smokers (n = 4488) from 2018-2020. Participants identified their preferred brand variety characteristics (no capsule; one capsule; two capsules), and reported perceptions of their brand varieties' flavor, smoothness, harmfulness, and whether they smoke to control their appetite. Separate multinomial logistic models regressed preferred cigarette type on sociodemographic and smoking-related variables, as well as perceived benefits on preferred cigarette type, adjusting for covariates.

RESULTS

Most participants preferred capsule cigarettes (single capsule = 47.5%; double capsule = 12.9%). Flavor capsule users reported that their preferred varieties mostly tasted like menthol/mint (59% of single capsule users and 23% of double capsule users), cucumber (12% and 27%, respectively) or berries (10% and 22%, respectively). Females were more likely than males to prefer either single or double capsule cigarettes (AOR = 2.26 and 2.01, respectively). Preference for flavor capsules was also higher among younger smokers, e-cigarette users, those who smoke less frequently, and those who recently tried or plan to quit. Smokers who preferred capsules were more likely than non-capsule smokers to perceive their cigarettes as smoother, less harmful, and to smoke to control their appetite.

CONCLUSIONS

The high prevalence of capsule use and widespread perceptions of the benefits of capsules over traditional cigarettes may help explain why tobacco control policies have not reduced smoking prevalence in Mexico.

IMPLICATIONS

Flavor capsules are rapidly growing in popularity in many countries around the world, including Mexico. This study found that more Mexican adult smokers prefer brand varieties with capsules (60%) than without capsules (40%), that flavor capsule use strongly correlates with menthol cigarette use, and that perceived flavors of capsules range widely. Flavor capsule smokers have more positive smoking expectancies (eg, lower risk perceptions, dietary control) than noncapsule smokers. Capsules appeal particularly to women, young adults, less frequent smokers, and those who recently tried to quit. Policies should consider banning flavors in cigarettes, including capsules and other filter innovations.

Prevalence of Menthol and Menthol Capsule Cigarette Use Among 11-16 Year Olds in Wales Prior to a Ban on Characterizing Flavors in Cigarettes: Findings From the 2019 Student Health and Wellbeing Survey

INTRODUCTION

The use of flavored cigarettes has increased in many countries because of the inclusion of one or more frangible flavor-changing capsules in the filter. Research suggests that these "capsule" cigarettes appeal most to youth, but little is known about how prevalent their use is among children.

METHODS

A cross-sectional school survey was conducted between September and December 2019 with 11-16 year-olds (N = 119 388) from 198 secondary schools across Wales; the sample represented approximately two-thirds of all 11-16 year-olds in the country. The sample was asked about smoking behavior, with a quarter (N = 26 950) also asked about awareness of menthol cigarettes, and use of menthol and menthol capsule cigarettes if a current smoker (N = 1447).

RESULTS

Current smoking prevalence was 5.7% among the entire sample and 5.9% among the analytical sample (those also asked about menthol and menthol capsule cigarettes). For the analytical sample, almost all current smokers (93.2%) were aware of menthol cigarettes, with three-fifths (60.5%) reporting having used menthol cigarettes in the past 30 days (42.3% capsule cigarettes, 18.2% noncapsule cigarettes). In comparison to nonmenthol smokers, those using menthol cigarettes (capsule and noncapsule) were more likely to be frequent smokers, with those using menthol capsule cigarettes more likely to have smoked for longer.

CONCLUSIONS

While past research suggests that flavored cigarettes appeal to youth, this study shows just how popular these products, and capsule cigarettes, in particular, were among young smokers in Wales. It also raises questions about why capsule cigarettes have received such limited public health attention.

IMPLICATIONS

That three in five 11-16 year-old smokers reported using menthol cigarettes in the past 30 days highlights how appealing these products are to young people, particularly capsule cigarettes, used by seventy percent of menthol smokers. Capsule cigarettes are one of the most successful tobacco product innovations in decades, even in countries with comprehensive bans on tobacco marketing and standardized packaging. The dearth of research on capsule cigarettes is a failure of global public health. Evaluation of the ban on characterizing flavors in the United Kingdom and across the European Union is critical.

Volatile organic compounds released in the mainstream smoke of flavor capsule cigarettes

In this study, the composition of mainstream smoke was investigated with an emphasis on a list of volatile organic compounds (VOCs: e.g., isoprene, acrylonitrile, methyl ethyl ketone, benzene, toluene, m-xylene and styrene) using the two types of flavor capsule cigarettes (FCCs, here coded as F1 and F2) in reference to one commercial, non-flavored (NF) and 3R4F cigarette. The concentrations of all the target compounds from FCCs were quantified under two contrasting conditions (i.e., with and without breaking the capsules). The effect of breaking the capsule was apparent in the FCC products with the enhancement of VOC levels, specifically between after and before breaking the capsules (e.g., 1.10-1.58 folds (benzene) and 1.30-1.53 folds (acetonitrile)). Such increases were apparent in both FCC samples if assessed in terms of the total amount of VOCs (TVOC): (1) F1 (from 2159 to 2530 μg cig-1 (p = 9.42 × 10-6)) and (2) F2 (from 1470 to 2014 μg cig-1 (p = 0.05)). In addition, these TVOC levels determined from the FCCs were 1.62- to 1.83- and 1.29- to 1.46-fold higher than those of the NF cigarette and the 3R4F cigarette, respectively. Thus, these FCC products are suspected to play a role as stronger sources of VOCs than the general cigarette products.

Strategies to enhance the effects of pictorial warnings for cigarettes: results from a discrete choice experiment

AIMS

To measure the effects of changing attributes of pictorial health warning labels (HWLs) on cigarette packs in a country that has already implemented pictorial HWLs.

MEASURES

For each choice set, participants were presented with two cigarette packs and asked the following three questions: (1) 'If only these two cigarette packs were available, which would you buy?'; (2) 'Each of these two packs has warnings on the front and back about the health effects of smoking. Which of these warnings best informs you about the dangers from smoking?'; and (3) 'Which warning most makes you think about quitting smoking?'. As recommended for best practices in discrete choice experiments, each of these questions was followed by an 'opt-out' question for participants to indicate whether they really believed there was a difference between the options presented (i.e. 'Would you really choose one of them?'; 'Do you really think that either of these warnings informs you about dangers from smoking?'; or 'Do you really think that either of these warnings would make you think about quitting smoking?', respectively). Each choice set could be viewed for as long as the participant wished. For each choice question (i.e. willingness to buy, informative, motivating to quit), the pack chosen was coded as 1 and the other pack as 0, with both packs being given a value of 0 if the participant 'opted out'.

DESIGN

A within-subject discrete choice experiment that involved systematic manipulation of pictorial HWL size [75 versus 30% (current policy)]; inclusion of imagery on the back of the pack [versus none (current policy)]; and color formatting [black on yellow versus yellow on black (current policy)].

SETTING

Mexico, on-line panel.

PARTICIPANTS

Adult smokers (n = 705).

MEASUREMENTS

For each choice set, participants selected one pack as having the most informative HWL about smoking harms, the one that makes them think the most about quitting and the one they were most willing to buy. We assessed the independent and interactive effects of HWL attributes on choices.

FINDINGS

Larger HWL size on the pack front (75 versus 30%) and inclusion of a pictorial image on the pack back were both independently associated with lower willingness to buy a pack [b = -0.228, standard error (SE) = 0.023 and -0.089, SE = 0.016, respectively] and greater perception of an HWL as informative (b = 0.214, SE = 0.022, and 0.191, SE = 0.017, respectively) and motivating to quit (b = 0.251, SE = 0.023 and 0.194, SE = 0.017, respectively). HWL with black text and yellow background were perceived as less informative (b = -0.037, SE = 0.016) and less motivating to quit (b = -0.032, SE = 0.015) compared with yellow text on a black background.

CONCLUSIONS

Among adult Mexican smokers, pictorial health warning labels on cigarette packages that are larger or cover both sides of the pack appear more effective at lowering purchase intentions and increasing risk perceptions and motivation to quit than smaller health warning labels or health warning labels with imagery only on the pack front.

Achievements, challenges, priorities and needs to address the current tobacco epidemic in Latin America

Most Latin American countries have signed and ratified the FCTC, although implementation has been uneven. Countries across the region were relatively quick to adopt mandatory smoke-free workplace policies, but regional progress in other areas has been slower. In taxation, for example, Uruguay and Brazil have made considerable progress while Paraguay and Bolivia have relatively weak policies. More recently, the region is grappling with challenges regulating novel tobacco and nicotine products. Market share for flavor capsule cigarettes in Latin America is the highest in the world; electronic cigarettes and heated tobacco products are, for the most part, dissimilarly regulated; and uptake of these emerging products by adolescents and young adults is on the rise. In examining the needs and challenges in the region, we conclude that the adoption of a strong regulatory framework based on the FCTC and its Protocols is needed to accelerate a positive public health impact. In particular, countries in the region need more consistent progress in implementing FCTC provisions while strengthening regulation of flavored tobacco products, electronic cigarettes and heated tobacco products. Failing to do so threatens to undermine the progress Latin America has made in tobacco use prevention and control.

"It's all About the Colors:" How do Mexico City Youth Perceive Cigarette Pack Design

Objectives: Cigarette packs are relevant to branding strategies, designed to appeal to specific groups. There is little research on how pack features increase product appeal among key constituents such as youth in low- and middle-income countries.

Methods: We conducted 10 focus group discussions (FGDs) with adolescents and 5 FGDs with young adult smokers in Mexico City, separated by age, gender, smoking, and socioeconomic status. Participants separated 23 cigarette packs into “appealing” and “unappealing” groups, and were asked to explain their decisions, describing the features that supported their views. FGDs were video-recorded, transcribed in Spanish, translated into English, and subjected to thematic analysis.

Results: Pack groupings did not differ greatly across FGDs; bold, contrasting colors and elements communicating flavor and promotion increased cigarette pack appeal and desire to try. Participants perceived packs with these features to be used by and designed for youth, like themselves.

Conclusion: Our findings reinforce the importance of packaging design in attracting new consumers and maintaining current ones. Mexico should consider stronger tobacco advertising policies that include packaging color and depiction of flavor to reduce product appeal.

Feminine Appeals on Cigarette Packs Sold in 14 Countries

Objective: Limited research has examined feminine marketing appeals on cigarette packs in low-and middle-income countries (LMICs). We reviewed a systematically collected sample of cigarette packs sold across 14 LMICs in 2013 (Wave 1) and 2015–2017 (Wave 2).

Methods: Packs in Wave 1 (n = 3,240) and Wave 2 (n = 2,336) were coded for feminine imagery and descriptors (flowers, fashion, women/girls, color “pink”). We examined trends in feminine appeals over time, including co-occurrence with other pack features (slim or lipstick shape, flavor, reduced harm, and reduced odor claims).

Results: The proportion of unique feminine cigarette packs significantly decreased from 8.6% (n = 278) in Wave 1 to 5.9% (n = 137) in Wave 2 (p < 0.001). Among all feminine packs, flower-and fashion-related features were most common; a substantial proportion also used flavor and reduced odor appeals.

Conclusion: While there was a notable presence of feminine packs, the decline observed may reflect global trends toward marketing gender-neutral cigarettes to women and a general contempt for using traditional femininity to market products directly to women. Plain packaging standards may reduce the influence of branding on smoking among women.

Cross-sectional survey of flavored cigarette use among adult smokers in Singapore

INTRODUCTION

Singapore, a city-state with a multi-ethnic Asian population, has one of the world's largest market shares for cigarettes with added flavors, such as menthol and fruit, which increase the appeal of smoking. Little is known on the sociodemographic or smoking-related traits associated with flavored cigarette use in the Asian context.

METHODS

A cross-sectional survey was conducted in January-March 2020 of 1123 Singaporean adult (aged 21-69 years) current smokers using a self-completed online or postal questionnaire. We used descriptive statistics and bivariate analyses to compare the answers of flavored and non-flavored cigarette users and fitted a multivariate logistic regression model to identify correlates of flavored cigarette use.

RESULTS

Of the respondents, 85.2% reported ever use and 52.7% of respondents with a regular brand reported current use of flavored cigarettes. Older age 40-49 years (AOR= 0.63) age ≥50 years (AOR=0.60), Indian ethnicity (AOR=0.39), and a moderate (AOR=0.57) or high (AOR=0.34) dependence level were correlated with non-flavored cigarette use, while female gender (AOR=2.53) and a later initiation age (16-20 years: AOR=1.72; age ≥21 years: AOR=2.19) were correlated with flavored cigarette use.

CONCLUSIONS

Consistent with findings from other countries, flavored cigarette use in Singapore is associated with being younger in age, female, of a certain ethnicity (Malay or Chinese), and having a lower nicotine dependence level.

Fresher with flavour: young women smokers' constructions and experiences of menthol capsule cigarettes and regular cigarettes

Background

Flavour capsule cigarettes are one of the fastest growing segments of the tobacco market, and there is evidence that Australian young people are increasingly using menthol flavoured capsule cigarettes. This qualitative research examines how young women construct and experience menthol flavour capsule cigarettes as part of their smoking practices, and explores the perceived differences between menthol capsule cigarettes and regular cigarettes. Semi-structured face-to-face in-depth interviews were conducted with 41 Australian young women smokers, using a constructivist grounded theory approach.

Results

Findings reveal that the perceived fresh and improved taste of menthol and the ability to customise the smoking process positively contributed to young women’s experiences of smoking menthol capsule cigarettes. In particular, menthol capsule flavour cigarettes were constructed by the young women as “fresh”, “light” and “minty”, and “popping” the menthol capsule allowed the young women to personalise their smoking experience.

Conclusion

These results indicate that specific public health campaigns and legislation should be developed to counter the powerfully alluring effects and the innovative appeal of menthol capsule cigarettes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-021-01297-2.